Planned complex suicide

A case report of complex suicide in physician: attempt drugs poisoning and adhesive tape asphyxia

Complex suicides are rare occurrences that can be categorized into planned (or primary) cases and unplanned (or secondary) cases. Additionally, individuals often select suicide methods based on their availability and accessibility. The body of a 58-year-old man was discovered deceased inside his medical office. He was found seated on the waiting room sofa, with his airways obstructed by several layers of adhesive tape wrapped around his head. An intravenous needle was observed in his left arm, and on the table in front of him, an empty 50 ml syringe, two empty vials of 10 ml potassium chloride, and an empty 10 mg vial of Valium (diazepam) were found. A roll of adhesive tape, similar to the one around his head, was also present. The autopsy, conducted 36 h after the body's discovery, revealed therapeutic concentrations of diazepam and its metabolite nordiazepam in the blood samples, while potassium chloride was not detected. Integrating forensic findings obtained from autopsy, histology, and other postmortem investigation, including toxicological analysis, can aid in defining suicidal behavior and preventing misinterpretation, particularly in differentiating diagnosis between homicide and suicide. It is crucial to consider circumstantial data and professional knowledge in such cases.

Death from exsanguination due to power drill injuries in a complex suicide: a case report

We present a case of a complex suicide of a 66-year-old man with a history of several psychiatric disorders. He attempted to commit suicide by inflicting cut wounds on his forearms, wrists, and neck but afterwards changed the method of suicide by using an electric power drill. After several unsuccessful attempts to drill a hole in either his head, thorax, or abdomen, he managed to perforate the common carotid artery on the right side of his neck and subsequently died from exsanguination.

Mechanical asphyxia by hanging and gunshot to the head: A series of rare planned complex suicides

A suicide where the deceased has employed more than one means of ending his or her life is defined as a complex suicide (CS). Forensic practitioners may face difficulties caused by the articulated mechanisms underlying this event. Among CS, the combination of hanging and gunshots is unusual. In this study, we present three unique cases of such planned complex suicides (PCS) that we have encountered in our 28 years of activity at the Bureau of Legal Medicine of Milan. Careful inspection of the death scene, precise analysis of the anamnestic-circumstantial data, and accurate medico-legal autopsy examination were the starting points for a better understanding of the causes and manner of death. In particular, the presence of vital reactions of tissues involved in the two different means used, the coherence of the areas involved with a self-inflicted wound, and the absence of signs of third party intervention allowed us to classify these events as suicides. As for the chronology of events, the lethality of the cerebral lesions caused by the gunshots in all cases, in accordance with the cervical lesions caused by hanging, led us to conclude that we were dealing with PCS and catalogue these three cases as unusually planned complex suicides avoiding incorrect and superficial classification.

Forensic remarks regarding 35 cases of complex suicides and 4 cases of complicated suicides investigated at the Institute of Legal Medicine of Brescia during the period 1983-2022

The role of the forensic pathologist is central to both identifying the cause and determining the manner of death. Distinguishing a suicide from a homicide or accidental event is essential to define whether third parties are involved in death. Suicides are most frequently performed using a single method; therefore, they can be defined as simple. The term "complex suicide" refers to a form of suicide in which two or more methods are applied by the victim, simultaneously or in chronological succession, to achieve the death. The different methods may have been planned in advance to prevent failure of the first method or may occur because the first method was not effective or was too painful, so the victim quickly seeks another way to complete the suicide. "Complicated suicides", on the other hand, are characterised by an unintentional secondary trauma following the suicidal act. This study analyses 35 complex suicides and 4 complicated suicides investigated at the Institute of Forensic Medicine in Brescia (Italy) during the period 1983-2022. Some data about the cases are discussed. This study aims to demonstrate how multiple lesions on the victim's body are not in themselves indicative of the intervention of third parties in their production, but complex and complicated suicides must always be considered.

Complex suicides involving the use of firearms and hanging: A retrospective study and review of the literature

INTRODUCTION

Suicides are the second most common cause of non-natural death in Germany after accidents. Most common is death by hanging, followed by the use of firearms. More frequent "simple" suicides in which one suicide method is used are distinguished from rare "complex" suicides, in which several methods are applied, whereby the combination of gunshot and strangulation is frequently chosen. Such cases require a thorough criminalistic and forensic medical examination to check the plausibility of assumed sequences of events and to detect covered-up homicides.

MATERIAL AND METHODS

A retrospective analysis of 5,400 post-mortem examinations at the Institute of Legal Medicine Giessen (2009-2018) revealed three cases in which gunshot and hanging were used to commit a planned complex suicide.

RESULTS

Case 1: The body of a 66-year-old carcinoma patient was found hanging from a tree in a kneeling position with a bullet through the head. The post-mortem examination revealed a penetrating head shot, uninjured soft tissues of the neck, no injuries to the hyoid bone or larynx and no signs of congestion. After autopsy, the gunshot through the head was considered as cause of death. Case 2: An 82-year-old man was found dead with two bullet wounds in the chest, hanging in free suspension in a factory hall. The necropsy showed two chest entry wounds with injuries to the heart and lungs as well as a vital ligature mark and fractures of the hyoid bone and larynx without signs of congestion. The combination of hanging and the gunshot wounds was concluded as cause of death. Case 3: The body of an 81-year-old pain patient was found in his home next to a small-caliber rifle, with a noose around his neck, attached to a suspension torn from the wall. The autopsy revealed a tangential shot through the skull with superficial injury to the frontal brain and a vital cord mark on the neck with fractures of the hyoid bone and larynx without signs of strangulation. In this case, hanging was identified as cause of death.

CONCLUSION

Complex suicides are rare events, that require a thorough criminalistic and forensic medical examination Although being called complex suicides and one of the methods usually being suitable to cause death, the cause of death is not always a combined one.

Is It Correct to Consider Caustic Ingestion as a Nonviolent Method of Suicide? A Retrospective Analysis and Psychological Considerations

BACKGROUND

Suicide methods chosen by victims are particularly critical in suicide risk research. To differentiate suicide deaths, it is usual to categorize them as violent and nonviolent depending on the detrimental method chosen by the victims. Caustic ingestion, for example, is traditionally considered as a nonviolent suicide method. It results in severe consequences for the human body and it is associated with high levels of lethality.

METHODS

In this study, we retrospectively analyzed suicides that occurred between 1993 and 2021 in Milan (Italy) and that underwent autopsy. We compared a sample of 40 victims that ingested caustic substances with a sample of 460 victims of other chemical ingestion, and a sample of 3962 victims from violent suicide. Univariate analyses and univariate logistic regression models were performed. Suicides from caustic poisoning were significantly older, had a higher mean number of diseases and were more affected by psychiatric diseases compared to other chemical ingestion victims. By contrast, caustic suicides, compared to violent suicides, had a more balanced gender ratio, a higher mean number of diseases, were more affected by psychiatric diseases, had a higher rate of complex suicides (more than one modality), and had victims who died more frequently inside instead of outside. In logistic regression models, age was the only feature differentiating caustic from other chemical ingestion suicides while the features differentiating caustic from violent suicides were gender, mean number of diseases and suicide place.

CONCLUSIONS

Suicides by caustic ingestion showed substantial differences compared to violent suicides, with a higher severe profile. However, some differences were reported comparing caustic ingestion to other chemical ingestion as well. Thus, we argue whether it is more appropriate to differentiate the suicidal ingestion of caustics from both violent and nonviolent suicide methods.

Sharp force fatalities: Differentiating homicide from suicide through a retrospective review (2012-2019) of autopsy findings in Lisbon (Portugal)

Sharp force fatalities may have a homicidal, suicidal or accidental manner of death. To aid in such differentiation this study aimed to identify medico-legal elements which were predictors of a given manner of death as well as to describe the characteristics of these deaths. A retrospective review was performed on all homicides and suicides due to sharp force injury admitted at the South Branch of the National Institute of Legal Medicine and Forensic Sciences between January 2012 and December 2019. Deaths with a performed external examination or forensic autopsy and with available demographic, circumstantial or necroscopic information were included. Each case was reviewed to collect said information and inferential analysis was employed with both parametric and non-parametric tests as well as binary logistic regression to identify independent predictors, with significance defined at α = 0.05. A total of 57 homicides and 20 suicides were identified, with the obtained demographic and circumstantial profile of the homicide victim being that of a young foreign male whose body was found outside home, with no weapon nearby and without a known psychiatric background. Homicides presented more prominently stab wounds, with these being conspicuous on the thorax and neck. Conversely suicides notably presented cut wounds, being critically present in the neck and upper limbs. Oblique thoracic stab wounds conveyed a homicidal death. Other findings that suggested homicide included the presence of clothing damage, additional traumatic lesions and injured lungs or bone/cartilage. Toxicologically, alcohol presence was associated with homicides while psychiatric drugs suggested suicide. The logistic regression identified the presence of additional traumatic lesions (OR 14.8, p = 0.032) and the absence of lethal neck (OR 0.109, p = 0.043) and lethal upper limb (OR 0.022, p = 0.015) wounds as independent autopsy predictors of a homicidal death. However, no single feature is infallible in establishing manner of death. To achieve a cogent conclusion, all investigative elements must be considered while attending to the specifics of each case.

Complex and complicated suicides in Friuli (1993-2017)

Complex suicides involve more than one suicide method. According to the intention of the victim, they are classified as 'planned' when the use of more than one suicide technique has been previously devised by the victim and 'unplanned' when the first method turns out to be too painful or insufficient to cause death, and the individual then resorts to other means of suicide. Complicated suicide, on the other hand, is a term that was introduced by Töro and Pollak, in which a failed act of suicide is followed by traumatisation, which has a fatal outcome. This type of death must be distinguished from complex suicides. From a sample of 1160 fatalities (837 males) between 1993 and 2017, we identified 20 (1.72%) cases of complex suicide and three (0.26%) cases of complicated suicide. We considered age, sex, psychiatric history, previous suicide attempts, suicide methods and eventual secondary traumatisation. We also compared planned and unplanned complex suicides. The results show a higher number of planned complex suicides (16 vs. 4), a prevalence of males (n = 17) and adults (median age = 48 years, range 21-74 range). Plastic bag suffocation and gas inhalation (n = 8) were the most commonly used methods. Firearms (n = 4) were used exclusively by males in planned complex suicides. Wrist and forearm cuts (n = 5) were found in four unplanned and one planned complex suicides, and all of the cases with known previous suicidal attempts (n = 3) involved planned complex suicides. Complicated suicides concerned three male victims in two failed attempts of hanging and an unforeseen carbon monoxide intoxication following a non-fatal gunshot to the mouth, confirming the rarity of these fatalities.

A forensic analysis on 53 cases of complex suicides and one complicated assessed at the Bureau of Legal Medicine of Milan (Italy)

Complex suicides are highly uncommon suicides in which multiple detrimental methods are used simultaneously or in chronological succession. We retrospectively analyzed through our database the 25512 autopsy reports registered at the Bureau of Legal Medicine of Milan in the last 27 years from 1993 until 2019, where 4498 suicides were documented. We assessed 53 cases of complex suicides and only one case of complicated suicide: for all of them we analyzed both data collected during the on-site investigation and the autopsy. In our case series, we identified a total number of 113 methods chosen and variably combined by the victims, which were classified into 17 categories. On the whole the most frequent association of suicide methods resulted in the combination of the plastic bag suffocation with inert gas inhalation (13 out of 53 complex suicides; 24.5%). We also analyzed our cases of simple suicides (1993-2019), to compare them with the complex suicides. In this study, we present a complete analysis regarding our cases of complex suicides, discussing the challenges and the interpretative issues which a forensic pathologist might deal with. A thorough on-site judicial inspection and a careful autopsy examination are crucial in such cases. Moreover, the clinical history of the victims and laboratory findings are supplemental elements to be necessarily considered to establish the actual manner of death and avoid any misinterpretations.

Forensic Pathological Considerations of a Unique Case of "Complicated Suicide"*,†

In the forensic literature, peculiar and uncommon cases of suicides defined as "complicated" are reported. In these circumstances, the suicide method chosen by the victim fails, and death occurs due to a subsequent unforeseen accidental event defined as secondary trauma. Through retrospective examination of 25,512 autopsies in 27 years (1993-2019) at the Bureau of Legal Medicine of Milan, a unique case of complicated suicide was identified from a total of 4497 suicides. It concerns an elderly man who, after killing his wife by inflicting incised wounds to her neck, tried to hang himself by tying a rope to a heater and jumping from the window located over the heater itself. However, the rope suddenly snapped and the man fells to the ground causing fatal traumatic injuries. Death occurred because of an accidental event caused by the failure of the hanging mechanism. Therefore, a peculiar yet characteristic case of complicated suicide is described.

A burned body with a gunshot wound in the mouth and a suicide note: A complex or complicated suicide?

The body of a 53-year-old man was found in a burning car. The ignition key was in start position and the accelerator pedal was held down by his right foot. Autopsy revealed a gunshot entrance wound in the hard palate, a bullet track through the anterior cranial fossa and a projectile lodged in the left frontal lobe. The brain stem was free of lesions and any signs of secondary brain injury, such as brain oedema and intracranial haemorrhage, were not significant. Soot deposits and thermal injury to the mucosa were observed in the airways below the glottis and carboxyhaemoglobin (COHb) saturation was 40%. A single bullet case and a handgun were recovered next to the driver's seat. Fire investigators identified the motor as the beginning of the burning: therefore, the conclusion was that the car had caught fire due to overheating of the engine. Differential diagnosis between complex and complicated suicide was essential. The cause of death was identified as carbon monoxide intoxication, and the injuries to the brain were not felt to be immediately fatal. The case has been classified as a complicated suicide. There are no other published cases of a complicated suicide involving exposure to fire or the use of firearms.

Skate or die: Unusual circumstances surrounding a natural cause of death

In a forensic pathologist's mind, a suspicious death scene involving inflicted injuries and a weapon always raises three possible hypotheses regarding the manner of death-homicide, suicide, or accident; the latter is slightly less common. We present a case of a 43-year-old homeless man with a history of chronic alcohol abuse who was found dead in a skate park in Geneva. He was inflicted with a stab wound to his abdomen, with a knife found in situ. With the suspicion of homicide, a crime scene investigation team, including a forensic pathologist, was summoned to the scene. However, further examination of the body revealed a deep cut with hesitation marks on the left forearm. This discovery raised the hypothesis of a suicide. Here, we have described the investigations made by the police and forensic department, along with the circumstances and autopsy findings that determined the cause of death as an effect of a natural disease.

Cut wrists, electrocution and subsequent drowning in a water drum: an unusual combination of methods in complex suicide

A 25-year-old male was found dead in a water drum inside the bathroom of his house one morning. Autopsy revealed a fatal right wrist cut, superficial cuts on middle phalanx of left index finger and features of ante mortem drowning. Investigation revealed the victim was an alcoholic and was depressed due to financial problems. On the previous night, under the influence of alcohol, he first tried to commit suicide by cutting wrist with razor blades, but death was not immediate. He then attempted electrocuting himself by touching a live wire, inside the bathroom, which failed and finally he drowned in a water drum. The victim had left a message, written with his blood on the floor of the room, reflecting his suicidal intentions. In complex suicide, many bizarre methods are used, but this combination of methods is unusual and not found in available forensic literature.

Complex suicide by self-stabbing with subsequent drowning in the sea

The paper presents a unique case of a complex suicide committed by a young man, mostly probably triggered by a disappointment in love. The uniqueness of the suicide lies in the fact that the victim inflicted several deep stab wounds on himself, in the chest and abdomen, while standing partly submerged in the sea and, having done so, he dropped and disappeared in the water. The postmortem examination showed, apart from deep wounds in the trunk, characteristics of drowning that manifested itself in the form of aqueous emphysema of the lungs. Suicide was clearly determined on the basis of the circumstances preceding death, the location, and arrangement of the trunk wounds and the testimony given by a witness of the incident. The circumstances preceding the suicidal act clearly suggest an underlying undiagnosed mental disorder.

Foreign object ingestion in complex suicide: a case report and review of the literature

Foreign body ingestion frequently occurs accidentally in the paediatric population as well as intentionally in prisoners to achieve hospitalisation, but is relatively uncommon in forensic cases and extremely rare as a method of inducing death in complex suicide. The reasons for this infrequency are many, not least the slowness of action and the lack of effectiveness in terms of lethality, regardless of the object used. In this article, we show an unplanned complex suicide carried out by ingestion of four plastic knives before hanging. Other complex suicides involving foreign body ingestion reported in the forensic literature are reviewed.

A series of complex suicide

This article presents 16 complex suicide cases. Complex suicide is defined as the use of more than one method to induce death. Of the victims, 10 were men and the ages ranged from 19 to 70 years. Eight victims left a suicide note. It was observed that 13 victims realized the suicidal act in the house and 5 victims had previous suicidal attempts. It was determined that 10 victims had psychiatric disorders, one of them had alcohol dependence. Six victims were housewives, 4 victims were unemployed, followed by one each victim of student, worker, farmer, tradesman, prayer leader, and animal husbandry lines of business. Ten victims were married; 3 victims were single; and 3 victims were divorced. On investigating the methods of suicide, it was seen that 9 victims preferred sharp instrument usage; 5 victims insecticide ingestion; 4 victims each firearms, medicine overdose; 3 victims each hanging, falling from a height; 2 victims self-strangulation; and 1 victim each drowning, liquefied petroleum gas and natural gas inhalation together, fungicide ingestion, rodenticide ingestion. It was determined that 2 victims used 3 methods and the other 14 victims 2 methods in company, to realize the suicide. In this article, the data obtained from our study was discussed by comparing similar data.

Planned and Unplanned Complex Suicides: A 5-year Retrospective Study

The notion of planned and unplanned complex suicides first appeared in 1974 by Marcinkowski and, since then, no systematic study of complex suicides has been published in the English forensic literature. Here, the authors present a 5-year retrospective study of complex suicides. Nineteen complex suicides were reviewed: five unplanned and 14 planned, including the first case of an unplanned complex suicide in a woman. All cases were analyzed in terms of gender, age, methods of suicide, the presence of a suicide note, and past suicide attempts, and statistically compared with a 50-case sample of simple suicides. A further comparison was established with compiled data from the literature. Similarities were revealed regarding incidence of complex suicides, male gender predominance, and types of methods used. In contrast, results showed a higher average age for planned complex suicide victims. Finally, the authors discuss the application of the complex suicide definition.

Criminal burning

We report a study of 40 burnt bodies on which an autopsy was carried out at the Institut de Médecine Légale in Lyon (28 men/12 women, average age = 41 years, minimum age = 3 years, maximum age = 86 years). Criminal deaths (31%) represented the second cause of death after accidents (52%), and before suicide (16%). Criminal burning seemed mainly to be means of covering up homicide, whereas criminal immolation was rarer. The particular characteristics of each of these situations have been highlighted (tying or poisoning in criminal immolation). We deemed it essential to make X-rays, to look for injuries due to trauma and to carry out systematic toxicological analyses in a victim of burning.

Planned complex suicide: Report of three cases

This article presents three planned complex suicide cases. The first case was a 46-year-old man, who had taken some antidepressant and antipsychotic drugs before cutting his right wrist and ingesting a large amount of concentrated hydrochloric acid. In the second case, a 34-year-old man was found dead in his home, hanging by his neck, with a suicidal stab wound on the left side of the chest. In the third case, a 22-year-old woman was found dead, hanging by her neck from a ceiling beam of her grandmother's a storage room, after taking of a solid rodenticide. The histories revealed psychiatric problems in all cases. The investigation of scene, the method employed, the autopsy findings and the interview with their relatives altogether pointed toward a suicidal etiology.

Vehicle-Assisted Suicide Resulting in Complete Decapitation

A rare case of vehicle-assisted suicide in a 43-year-old man is presented. The man had tied a rope between a fence and his neck and, while seated on the driver's seat, accelerated the vehicle, which resulted in complete decapitation. Earlier that day, the man had tried to bleed himself to death by bottling his own blood in his flat, thus defining the case as secondary complex suicide.

Planned complex suicide

Two cases of planned complex suicide are presented. In both cases, the suicidal persons shot themselves after making sure that in the sequel their bodies would be burnt. In the first case, a 65-year-old man had shot himself in the mouth and consequently fell into a fire he had lighted before. In the second case, a 43-year-old man set fire to his flat and shot himself directly afterwards. On the basis of the reported cases, a short literature review on planned complex suicides is given.

Suicide with two guns represents a special type of combined suicide

Suicide by simultaneous gunshots with two firearms is rare. The case of a 90-year-old man who killed himself with two 6.35 mm pistols fired at the temples at the same time is presented. The victim was found dead on the terrace of his home; two guns and two cartridges were present near the corpse. Cases of suicides with two guns published in the literature are compared, and the Italian cases are illustrated briefly. The authors describe the circumstances and autopsy findings that permitted the assertion that it was a case of suicide and to exclude an homicide and show, by figures, the three-dimensional reconstruction of cranial shooting injuries. The use of two guns is considered a representation of a special type of "combined suicide" or "planned complex suicide."

Planned complex suicide: report of three cases

Three cases of planned complex suicide in a 3-year period are reported. A 40-year-old man was found dead, in his garage, hanging by his neck, with a gunshot in the head from a pen gun. A 50-year-old man was found dead in the sea with a gunshot to his head. A third man was found in a field hanging by a tree and burned. The investigation of the scenes and the methods used pointed toward a suicidal etiology. The main difference between planned complex suicide and those cases defined in medicolegal literature as combined suicides lies in the complex mechanism used by the victim as a protection against the failure of one of the mechanisms.

Planned complex suicide. An unusual suicide by hanging and gunshot

We report a case of planned complex suicide (PCS) by a young man who had previously tried to commit suicide twice. He was found dead hanging by his neck, with a shot in his head. The investigation of the scene, the method employed, and previous attempts at suicide altogether pointed toward a suicidal etiology. The main difference between PCS and those cases defined in the medicolegal literature as combined suicides lies in the complex mechanism used by the victim as a protection against a failure in one of the mechanisms.